Illicit drug use continues to be a prevalent and growing problem in the United States. Data from the Substance Abuse and Mental Health Services Administration national survey indicate that over the past 6 to 7 years, there has been a notable upswing in “daily or almost daily” marijuana use. “It is thought that this trend is in part due to aging baby boomers, who have not given up the habit, as well as new, younger users in a kind of grandfathered effect,” noted Ernest J. Dole, PharmD, PhC, FASHP, BCPS, of the University of New Mexico Hospital’s Pain Consultation and Treatment Center.
Dr Dole also noted that marijuana use is far more prevalent among persons aged 18 to 25 years. In 2012, 21% in this age group had used marijuana in the past month compared with 7% of persons 26 years and older. Also, marijuana use outweighed the use of cocaine and psychotherapeutics (ie, prescription stimulants).
In addition, the use and abuse of newer substances is becoming more common in the United States. This trend may be driven by changes in the legal status of existing substances of abuse and increased difficulty in obtaining prescription drugs for nonmedical use. These factors are encouraging users to look for options that are “barely legal,” less expensive, more readily available, or have more desirable pharmacologic effects.
In some cases, the primary reason for the use of newer drugs is to avoid detection. Dr Dole noted, “Those who are breaking the law are typically 2 to 3 years ahead of those who obey the law. They often tweak their products just enough to avoid current screening tools, and by the time the tests catch up, the drugs are altered again.” Because of the difficulty in screening and identifying agents, practitioners often have to rely on signs and symptoms to identify drug abuse among patients who present for medical care.
Some of the “barely, but still, legal” drugs are those of herbal origin that, when used in sufficient (and abundant) quantities, produce the desired effects. Individuals who use these products may not realize they are doing something harmful because the products are legal, and the users rationalize that they are “using all-natural things.”
Angela G. Huskey, PharmD, CPE, from the University of Florida College of Pharmacy, continued the discussion by reviewing some of the more commonly abused and recently newsworthy products, such as “bath salts,” more scientifically known as synthetic cannabinoids and synthetic cathinones.
Synthetic cannabinoids (ie, Spice, K2, Yucatan fire, black mamba) were first identified internationally in 2004. Although banned in Europe and Russia in 2010, they made their first appearance in the United States around 2009 to 2010. At the time, they were marketed as a “safe alternative” to marijuana. The active ingredients are commonly sprayed onto other plant materials such as incense, potpourri, and air fresheners.
The effects of synthetic cannabinoids are similar to those of tetrahydrocannabinol, but are commonly exaggerated. They include elevated mood, relaxation, and altered perception, but also tachycardia, paranoia, anxiety, and hallucinations. In some cases, urgent medical care is required. Deaths associated with their use have also been reported. Additionally, some effects are mixed because individuals may experience the effects of the synthetic cannabinoids as well as the herbal products with which they may be used.
Synthetic cathinones (ie, bath salts) are derivatives of cathinone, an active compound from the khat plant. Cathinones are central nervous system stimulants similar in structure to amphetamines. The most common versions are methylone and methylenedioxypyrovalerone.
Cathinones are indirect sympathomimetic agents that enhance the release of and inhibit the reuptake and breakdown of norepinephrine, dopamine, and serotonin. The effects of these compounds are similar to other amphetamine-like medications and include euphoria, heightened alertness, and increased energy as well as hypertension, tachycardia, hyperthermia, dehydration, and psychomotor agitation.
Fortunately, data suggest that exposure to bath salts has diminished significantly since 2011 with the awareness of their abuse and the change in legal status.
Closing the session, Jennifer M. Strickland, PharmD, BCPS, also from the University of Florida College of Pharmacy, presented information about a few other common substances of abuse, including:
Kratom, a legal plant product from Southeast Asia, which is commonly used as a tea and is available through the Internet. The active substance is the alkaloid mitragynine, which has activity at the mu- and delta-opioid receptors. The effects are dose dependent. Lower doses are associated with stimulant activity and higher doses have opioid-like effects.
Salvia (salvia divinorum), an herb native to Mexico, in the mint family (ie, mystic sage and magic mint). The psychoactive agent present in this herb is salvinorin A, which is responsible for its hallucinogenic effects. The FDA has considered salvia a “drug of concern” since 2004, but no formal federal ban exists. However, it is illegal to possess or distribute salvia in several states.
Krokodile, whose active ingredient is desmorphine. Krokodile, or kroc (croc), is synthesized from codeine and numerous other products including paint thinner, gasoline, and red phosphorus (from matchbook strikepads). The product originated in Russia as a heroin substitute, and got its name from the severe skin complications (eg, skin necrosis, gangrene) arising from persistent use. These complications often require amputation, and abusers often die within 2 to 3 years because of associated health conditions. Dr Strickland noted that because the drug can be synthesized within an hour and the onset of action is rapid (as is the “crash”), heavy users often do not leave their homes.